Learning after acquired brain injury Learning the hard way Hileen Boosman Layout H.Boosman Printed by Proefschriftmaken.nl | Uitgeverij BOXPress ISBN 978-90-393-6399-7 © 2015 H. Boosman All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage or retrieval system, without written permission from the author. The copyright of the articles has been transferred to the respective journals. Learning after acquired brain injury Learning the hard way Leren na niet-aangeboren hersenletsel Het is niet vanzelfsprekend (met een samenvatting in het Nederlands) Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof.dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op donderdag 24 september 2015 des middags te 12.45 uur door Hiltje Boosman geboren op 9 oktober 1985 te Oldeberkoop Promotoren: Prof.dr. J.M.A. Visser-Meily Prof.dr. C.M. van Heugten De in dit proefschrift beschreven studies zijn mogelijk gemaakt door financiële steun van het Nationaal Initiatief Hersenen & Cognitie (NIHC). Dit quick-result project maakt deel uit van de pijler ‘Het Gezonde Brein, Programma Cognitieve Revalidatie’ (subsidienummer: 056-11- 014). De totstandkoming van dit proefschrift werd mede mogelijk gemaakt door financiële steun van de Stichting De Hoogstraat Onderzoeksfonds te Utrecht, De Hoogstraat Revalidatie en Adelante Zorggroep, Hoensbroek. Contents Chapter 1 General introduction 7 Chapter 2 Clinicians’ views on learning in brain injury rehabilitation 13 Chapter 3 Dynamic testing of learning potential in adults with cognitive 23 impairments: A systematic review of methodology and predictive value Chapter 4 Validity of the dynamic Wisconsin Card Sorting Test for assessing 45 learning potential in brain injury rehabilitation Chapter 5 Exploring the relation between learning style and cognitive 67 impairment in patients with acquired brain injury Chapter 6 Validity and feasibility of a learning style instrument for brain 79 injury rehabilitation Chapter 7 Predictors of health-related quality of life and participation after 95 brain injury rehabilitation: The role of neuropsychological factors Chapter 8 General discussion 117 Summary 129 Samenvatting (Summary in Dutch) 135 Dankwoord (Acknowledgements) 141 About the author 145 CHAPTER 1 General introduction Chapter 1 | General introduction General introduction | Chapter 1 Acquired brain injury Acquired brain injury (ABI) is a major cause of death and disability worldwide with an estimated number of 160,000 cases annually in the Netherlands.1 ABI refers to a sudden- onset neurological condition which is not of congenital, hereditary, or degenerative nature nor induced by birth trauma.2 It is an umbrella term that includes traumatic and non-traumatic brain injury. Traumatic brain injury occurs when an external force injures the brain, such as a car accident or a blow to the head. Non-traumatic brain injury is caused by internal events such as a stroke or a brain tumour. Both traumatic and non- traumatic brain injury can cause enduring physical deficits such as paralysis and impaired coordination.3 There are also many ‘hidden’ consequences of ABI that can affect patients’ neuropsychological functioning.4 Neuropsychological problems frequently faced by patients with ABI are depression, poor self-awareness and impairments in memory and attention.4 Patients with ABI are often referred to a neuropsychological rehabilitation program to learn how to manage such ‘hidden’ deficits.4 Neuropsychological rehabilitation Neuropsychological rehabilitation is specifically concerned with the management of emotional, behavioural and cognitive problems following brain injury.4 The ultimate goal of rehabilitation is to optimize patients’ social participation and quality of life.5 Rehabilitation generally involves a four-step process: assessment, goal setting, intervention, and reassessment.5 First, the patient’s needs and problems are identified. Second, realistic and attainable short- and long-term goals are set. Third, the planned interventions are executed. Fourth, the effects of the interventions are evaluated against the goals set. The focus of rehabilitation treatments is on learning. Learning is commonly defined as “any relatively permanent change in behaviour that occurs as a direct result of experience”.6 This ranges from learning or relearning practical (e.g., learning how to use an agenda as an external memory aid) to psychosocial skills (e.g., learning how to cope with fear of recurrence). A measurable, observable or inferred change in knowledge, skill or attitude suggests that learning has occurred. Obviously, when the organ that is responsible for learning – the brain – has suffered damage, the learning process can be considerably disturbed. Brain damage can influence what is learned, but also how learning takes place. Learning: what? What patients can learn is often discussed by clinicians in terms of learning ability. Despite the lack of a thorough scientific basis, a patient’s degree of learning ability is often mentioned as an important prerequisite for treatment success. For example, a patient with substantial memory impairments but low learning ability and poor self-monitoring skills may not profit from being taught memory strategies.7 In clinical practice, neuropsychologists are 8 9 Chapter 1 | General introduction General introduction | Chapter 1 frequently consulted to estimate patients’ degree of learning ability.8 A comprehensive neuropsychological assessment can give valuable information about impairments that may hamper or facilitate the learning process and consequently about the feasibility and type of treatment required.9 Relatively intact executive functions are, for example, required to generalise learned behavior to other tasks and situations.10 Although several cognitive tests have been suggested for the assessment of learning ability,9,11 it is not yet known whether psychologists actually use specific cognitive tests or assessment tools to assess patients’ learning ability. Each cognitive tests basically measures one specific aspect of learning ability. Neuropsychologists can obtain further information about patients’ cognitive abilities by going beyond the standard instructions of the test for instance by using a testing-the-limits procedure.11 When the patient’s limits are tested, extended time or attempts are allowed in order to evaluate the patient’s maximum abilities on the test at hand.12 This provides additional information about a patient’s “approach to the task and ability to accurately complete the test if given enough leeway”.12 Testing-the-limits is an example of a dynamic testing procedure.13 The aim of dynamic testing procedures is to investigate performance change brought about by deliberate and often standardized intervention by the examiner.14 The degree of change in cognitive performance is generally used to indicate patients’ degree of ‘cognitive learning potential’.15 Dynamic testing procedures, such as testing-the-limits, can be applied to basically all conventional cognitive tests.11 Dynamic testing procedures are intended to supplement and enrich conventional cognitive tests to deepen insight into patients’ cognitive functioning particularly in the domain of learning. Despite the potential merit of such procedures in assessing patients’ abilities, particularly with regard to learning, most studies on dynamic testing were performed in educational settings. To date, relatively little is known about dynamic cognitive testing procedures in patients with cognitive impairments such as ABI. Learning: how? Learning is commonly viewed as a ‘black box’ as it is mostly examined in terms of input and output without specific knowledge of its specific underlying processes. When attempting to maximize patients’ learning output, information about learning processes is paramount. Such information can be used to tailor treatment to patients’ strengths, weaknesses and preferences in the process of learning. Currently, rehabilitation treatments are commonly based on a ‘learning by doing’ approach.16 In the process of learning or relearning skills after ABI, mere practice does not necessarily suffice. What is needed is an optimum learning environment to overcome learning barriers, facilitate learning, and maximize the maintenance and generalisation of learned skills. In an optimum learning environment, 8 9 Chapter 1 | General introduction General introduction | Chapter 1 teaching strategies are tailored to best suit individual needs. Clinicians can, for instance, be more or less directive and persuasive depending on patient characteristics and the treatment target of interest.17 The concept of learning style was introduced based on the premise that adapting instructions and teaching strategies to a person’s learning style may facilitate the learning process (‘matching theory’).18 Learning style is the way a person prefers to approach or choose a learning situation.19 Imagine a patient who learns how to use an electric wheelchair. Some patients will prefer to learn by hands-on experience, in a trial-and-error manner, whereas other patients prefer to learn by observing others and thinking about it first. More than 71 learning style models have been described of which most were developed for healthy individuals in educational or vocational settings.18 Although the term ‘styles’ seems to imply a fixed trait which is stable over time, several models consider learning style as flexible, context-specific or even task-specific.18,19 Also, the extent to which learning style models pay attention to personal and environmental factors varies widely.18,19 One of the most influential learning style models is Kolb’s experiential learning theory (ELT)20 which regards learning as a continuous and interactive process. According to Kolb’s ELT, learning preferences are relatively flexible and can change slightly from situation to situation.18,20 In the year 2000, Kolb’s ELT was already applied in over 1000 studies in several fields (e.g., management, computer studies, education).18 To date, Kolb’s ELT has not yet been examined in ABI rehabilitation. The role of learning in predicting rehabilitation outcomes Besides assessing patients’ abilities and preferences in the area of learning, it is of interest to determine whether such information contributes to predicting patients’ functioning on the long term. Given the high inter-individual variability in rehabilitation outcomes, prognostic indicators are required to provide a more accurate prognosis and to stratify patients for the risk of poor outcome. Rehabilitation outcomes are commonly expressed in terms of activities limitations and participation restrictions.21 These concepts are derived from the widely used ‘International Classification of Functioning, Disability and Health’ (ICF) conceptual framework of the World Health Organisation.22 Activity limitations are problems a patient may experience when executing certain activities.22 Participation restrictions are difficulties patients may have that influence their involvement in life situations.22 A patient may, for example, be unable to remember appointments (activity limitation) which causes difficulties with work or the patient’s engagement in leisure activities (participation restrictions).4 In the ICF activities and participation domain, learning occupies a prominent position. The first chapter within activities and participation is ‘learning and applying knowledge’. This chapter includes purposeful sensory experiences (e.g., watching, listening), basic learning 10 11